Assoc Prof Harry Mond
February 23, 2026
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Phillip sent me this ECG from the Royal Melbourne Hospital.
Thanks Phillip.
22-year old unconscious inebriated male involved in a motorcycle accident.
Widespread trauma including cranium and sternum.
Pre-operative ECG requested by anaesthetist, whilst awaiting urgent neurosurgery.
What do you think?
The poor R waves and ST elevation in the chest leads (red highlight) could be interpreted as within normal limits or early repolarization in a young male. There is reciprocal ST depression in lead III(yellow highlight) which should alert the reporter to possible myocardial ischaemia/infarction. The most striking feature, however, is the prominent tall symmetrical peaked T waves in the same leads as the ST elevation (red highlight). These are hyperacute T waves seen very early with an acute myocardial infarction. This feature is rarely commented upon because it is very transient and already resolving as other more visually apparent diagnostic features on the initialECG, such as ST elevation and Q waves, begin to emerge.
Those who report 12-lead ECGs are familiar with the auto-interpretive diagnosis regarding tall T waves as being “suggestive of acute ischaemia”. As an isolated feature, the diagnosis cannot be made unless there is a history of chest pain or at least other early changes as seen on our ECG and in particular, the reciprocal changes.
Another example of hyperacute T waves (red highlight).
Smaller T waves can still be regarded as hyperacute, provided they are relatively large in relation to its accompanying R wave.
Two-days later, the 12-leadECG revealed extensive anterior transmural ST elevation myocardial infarction(yellow highlight) due to trauma to the left anterior descending coronary artery. The transient hyperacute T wave changes were localized to the site of the infarction
Did I hear someone suggest that these early changes may be related to intracranial trauma?
Marked changes on the 12-leadECG may occur as a result of severe acute cerebral trauma and in particular cerebrovascular accidents and cranial injuries. Reported ECG changes include:
The incidence of the ECG changes with severe cerebral trauma varies considerably in the literature with deep inverted T waves being the most common. ST elevation is very rare. Other rhythm disturbances include sinus tachycardia and ventricular ectopy. The findings are transient with the mechanism related to the sympathetic nervous system. Acute gall bladder and biliary disease can cause bradycardia and non-specific ST/T wave changes also related to heightened vagal tone.
Harry Mond
October 29, 2026
As its name implies, AVNRT is a reentrant junctional or supraventricular tachyarrhythmia which involves the fast and slow pathways within the AV node creating a self-perpetuating circus movement. It can be divided into typical (slow-fast) or atypical (fast-slow) as well as several rarer forms related to more than one slow or fast pathway with similar electrophysiological properties. On the ECG, they can be identified and differentiated by the positioning of the P wave in relation to the QRS complex, which in turn is related to the direction of the re-entrant AV nodal circuit. However, in about 60% of cases, the P wave is buried in the QRS/T and cannot be identified on the surface ECG.
October 16, 2026
Retrograde conduction is defined as conduction from an ectopic site to the atrium via the AV node or accessory pathway and referred to as VA conduction. II results in a P wave configuration which differs from an anterograde P wave, and in most ECG leads is inverted. The site from where the impulse originates can be the AV node, Bundle of His, distal conducting system or the body of the ventricles including ventricular pacing. On the ECG, the QRS complex usually precedes the inverted retrograde P wave but on occasion may follow it.
October 1, 2026
In 1970, I commenced work as a “novice” cardiologist at The Royal Melbourne Hospital. Training at that time was learning how to recognise the diastolic murmur of mitral stenosis and making sure the ECG and chest x-rays were the correct way up. As this was prior to coronary artery surgery, stenting and echocardiography, the ECG was a highly respected tool for the diagnosis of many conditions. I was fortunate to befriend a number of the gurus of ECG interpretation who taught me to look into the soul of an ECG. Today, even though the ECG is the first investigation performed by a cardiologist, the art of ECG interpretation has been lost because we depend on the new tools for cardiac diagnosis.
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